Healthcare Provider Details

I. General information

NPI: 1033215314
Provider Name (Legal Business Name): MICHAEL W BENNETT DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N CAPE ROCK DR
CAPE GIRARDEAU MO
63701
US

IV. Provider business mailing address

1200 N CAPE ROCK DR
CAPE GIRARDEAU MO
63701
US

V. Phone/Fax

Practice location:
  • Phone: 573-334-8013
  • Fax: 573-334-4101
Mailing address:
  • Phone: 573-334-8013
  • Fax: 573-334-4101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CONNIE RESSEL
Title or Position: OFFICE MANAGER
Credential:
Phone: 573-334-8013